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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700580
Report Date: 11/21/2022
Date Signed: 11/21/2022 11:18:01 AM

Document Has Been Signed on 11/21/2022 11:18 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:WALTERS RESIDENTIAL HOME CARE 3FACILITY NUMBER:
392700580
ADMINISTRATOR:CRISTOPHER WALTERSFACILITY TYPE:
735
ADDRESS:1335 MINE STTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 4CENSUS: 5DATE:
11/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joseph NimeneTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPA) Kesha Lewis and Albert Johnson conducted a case management visit as a result of the incident that took place on November 13th 2022. LPA met with the facilities administrator and explained the purpose of today's visit. On 11/13/22.

R1 had a altercation with R2 from his care home that resulted in R1 getting (3) three scratches on their neck. Staff as able to treat the scratches themselves with first aid. Per staff, R2 was accusing R1 of stealing a DVD and was banging on R1'S room door per staff this is not the first time this type of incident for R2 has occurred. This behavior is identified in his IPP and as a result.

LPA obtained information from R1 and R2'S file.

Based on today's visit, no deficiencies are cited. Advisory given.

Exit interview and copy of report provided
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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